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N74
LLAGE OF— -R BROOKBUILDING DEPARTMENT UILDING DFPARTMBNT
VILLWE OF RYE BROOK
938 Kiw STAI I.1 RN I BROOK,NY 10573
(9141939-060
ELECTRICAL PERMIT APPLICA110N
Wesicbester Count) Master Electricians License Required
volt 0FF1C t F SE(�♦
appro,al Date: _ _ Permit Fee:$—
Apprusal.%Xnature: thber:
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kppit.atton dated c is hcrch\ made to the littikling InNbector of tlic Village of Rye Brook NY.for the is.uancc of
a Pcrmit to install and or remove electncal equipment,wiring,futures.or to pt rl'orm other Irish or low voltage electrical work as per
the detailed a:atcment dexribed below. By signing this document, the applicant & prupiaty uwner agree that all electrical work
performed a ill be in confor nancc w ith all a We I'twk°ral,Stab;,County and Local Codes. / p --7
1.Addrc<s C' �%t' '�r C SBL: ,(p Zone,k_
:_Proper:. (Y*n.-r -,G-14 -- / i 10 AdJrrss: C 3 /r#
Phone,; L cell P: email: e�, ' c t 3C�7 V- yw&d-
3.toaster Electrician Licensed Installer :r �� h u Address: • 1 t /O
Lic.!: r Y(G Phone:�: �� II .4(h C1115.—z
Compan� Name �c{7 tCa 7 Sfr.•t j'i fr -rS Address: c/5
4.Proposed Electrical Work/fizlurc Count
LV
5.3"Party Electrical Impcown Agenc%: �
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// %TAT) 01-NI-W YORK_WUNTY OF WF.STC•HF-STI-R 1 as.
duly vimi n.dgww%and Woad that he�hc is the applicant ahm a narivi,and do—further
//
stn'e that r,the i,the�(15 f•I/-Eleic 411'k (or the leuai owner and is dul%authori.PW to make and file this application.
The undersigned libriher states that all jaienienE,curvained herein are true to the tart of his her kiwwltdge and belief.and that am we&-
perfeimkd.or u>.cnnduu.d at ilx ah . captkukti!prupen) a ill tk in cex forniaricc w ith the dctatl,a.art Cloth and contained in thie
application and in any accompanying appro%cd plan,and,fxcrfications.as well as in accordance with the New York Sure Lniform fire
Prcicnw-n&Building(otle.�UbeCi-Jc ofila Village of R}c llnwk and all txhcr applicable lrw in>ort a ces.and rcgulatKtiis.
Swom to 1
before me this �t 1 Sworn to bei' a me this _
rday of cwnk(Le .20 day of 20 _
i d
pta0urc of Property C)vc-iner t of Applk-ant —
., rt
Pt•erst of'P ow Print Cot bran[ `
J Pt a STEPHANIE L GOMEZ Notary 1'uhic
ry r
II0TAIIY Pi1BLlC-STATE OF NEW YDRK �`
No,01 G0e344e44 ►u w�,r;
Deborah Romano
Notary Public Reg.No.
OIR04636916
Commision Expires:/,/A(,
STATE WIDE INSPECTION SERVICES, INC.
Service With Integrity
0•0 r •
SWIS JOB APPLICATIONi. •
Office Use Elect. Permit# J-/_ 0 3 Date
Bldg Permit# Scl Ft
Plumbing Permit#
Final Certificate #
City/Village ?` Uc K Zip r7 3 Building Dept. ` �y County
Address Gj� Cross Street 7 Section Block Lot
Owner Name/Address(lf different than above) Contact Number
Basement ❑1st Fl. ❑ 2nd Fl. ❑3rd Fl. ❑More Than 3 Fl. arage ❑Attic ❑Outside ❑Residential ®Commercial
Receptacles Special Recept GFCI AFCI Switches Dimmers Smoke Alarms C/O Detector Hood Trash Compact
Amt Amps
Range(s) Cooktop(s) Oven(s) Dishwashers Refrigerator Disposal Microwave Luminaires Generator Transfer Switch
SERVICE
Amperage #Panels 1P 3P # Meters # Disconnect ❑Underground ❑ New ❑ Reconnect ❑ Repair
❑Overhead ❑ Upgrade ❑ Disconnect
Utility ID# ❑Con Ed ❑NYSEG ❑Central Hudson ❑ Orange/Rockland
PHOTOVOLTAIC SYSTEM
PV Modules Inverters AC Disconnect ]unction Box Combiner Box Load Center PV Monitor Energy Storage System DC Disconnect
❑Legalization ❑ Safety Inspection ❑Consultation
�l
FE3 - 6 2024
r
6,GE OF Ry- E-'
Di�4� DEPA i EN7
This application is valid for one(1)year from the date received by Wis.This application is intended to cover the above listed items to be inspected,far any time of Inspection additional items have been installed,you are
authorized to make the inspection and adjust the fee for the additional items inspected.The applicant declares that there Is no open applications for the above address with any other inspection company.The applicant,
owner or authorized agent agrees to all the above terms and conditions as set forth for the application.
Email Address 4 � C L �- ' �. n
V �� [ `f/f Cc�� �� • i�l'7�N c�fLf S. (�, Name �� �,,/
License# 1 /C- Date ��_ Signature
Address C�n City/State A Zip Code
Company ec' -y' re,, Phone#